Using Technology to Align Treatment with End-of-Life Goals

Session ID 105, February 13, 2019

Kathy Blanton, RN, BSN, CPHQ, CPHRM

Director, Patient Health Management, Sutter Health

Ryan Van Wert, MD, CEO, Vynca

Kathy Blanton, RN, BSN, CPHQ, CPHRM

No real or apparent conflicts of interest to report.

Ryan Van Wert, MD

CEO, Co-founder and Chairman of the Board, Vynca

Conflict of Interest

Ryan Van Wert, MD

Salary: Yes

Royalty: No

Receipt of Intellectual Property Rights/Patent Holder: No

Consulting Fees (e.g., advisory boards): No

Fees for Non-CME Services Received Directly from a Commercial

Interest or their Agents (e.g., speakers’ bureau): No

Contracted Research: No

Ownership Interest (stocks, stock options or other ownership

interest excluding diversified mutual funds): Co-founder, CEO and

Chairman of the Board, Vynca

Other: None

Conflict of Interest

• The value of advance care planning (ACP)

• Physician Order for Life-Sustaining Treatment (POLST) form

• POLST/ACP state registries

– California eRegistry Pilot

• Sutter

– The need for an ACP solution

– Evaluation process

– Key change management strategies

– Implementation

– Learnings

– Metrics for success

• eRegistry value prop and success

• A look at Oregon

Agenda

• Explain the purpose and goals of implementing an EMR-

integrated eRegistry ACP technology platform across the health

system and state registry

• Assess the value proposition of a dedicated ACP technology to

coordinate the sharing of POLST information across the medical

community

• Show how the use of a dedicated ACP technology improves

patient engagement, system utilization, ACP document capture

rates and impacts unnecessary admissions and ICU utilization

• Define the implementation and change management strategies

needed for success

• Identify organizational readiness for participation in a POLST

eRegistry

Learning Objectives

Advance care planning (ACP) is a lifelong process of personal

reflection to determine and document future care preferences.

To be successful, ACP must:

• Help the individual accurately reflect on their values

• Provide sufficient health-related information from the care team to

fit values within a specific context

• Be documented in a way that is legal (usually at the state level)

• Be conducted in appropriate settings

• Be available in appropriate settings

What is Advance Care Planning?

≠

The Current State of Advance Care Planning

A rare opportunity to:

• Improve quality care at an important time of life

• Improve family experience

• Reduce unwanted utilization

• Achieve quality and value metrics

• Achieve cost savings

What is the Value of ACP?

ACP Supports Quality and Value Metrics

30%

83%

43%

Reduction in-

hospital deaths

Increase in hospice

use

Reduction in

hospital admissions

through systematic

post-acute ACP

program

Teno et al. JAGS 2007; 55:189-194; Molloy et al JAMA 2000; 283(1437-1444)

ACP Improves the Patient Experience

Primary care: 686 patients over 75 years old, or over 50 with chronic illness

J Gen Intern Med. 2001 Jan;16(1):32-40, Detering et al., BMJ. 2010 Mar; 23(340):c1345

Hospitalized patients: 309 elderly patients randomized to ACP or usual care

34%

51%

65%

93%

ACP Document Types

ADVANCE

DIRECTIVES

LIFE SUSTAINING

TREATMENT FORM

STRUCTURED

GUIDES

• Form to guide conversations

and communicate goals for

patients and providers

• Self-developed or third party

• Specifies actions if patient is

no longer able to speak

• Living will, medical directive,

advance directive

• Form to capture and honor

treatment preferences of

seriously ill

• POLST, MOLST, MOST, etc

• Serious illness or frailty

– Generally used when death is expected within a year

• Communicates treatment wishes valid in the outpatient setting

– Attempt CPR or not; if no pulse or breathing

– Other medical intervention/treatment:

• Full – Selective – Comfort Focused

– Artificial nutrition wishes

• Designed to ensure care concordant with patient wishes

– Emergency medical services personnel

– Emergency Department personnel

• MD with patient makes final call

– Nursing facility staff

– Clinic staff

– All other providers

Value of the POLST Form

STORE

ACCESS

CAPTURE

• ADT/FTP

• Web portal

• HL7

• Electronic completion

• Centralized, HIPAA compliant

database

• Patient matching

• Call center

• ED eFax

• Web Portal

Technical Components of a State Registry

• Not-for-profit Integrated Healthcare

System

Numbers

• Large ambulatory network: Ambulatory

Surgery, Urgent Care, Walk-in centers,

Home Health, AIM, Hospice

• 24 hospitals and 4,259 Licensed Acute

Beds to include 5 trauma centers

• 191,000+ Discharges 2017

• 868,000+ ED visits 2017

People Make the Network

• Partner with more than 12,000 doctors

• 53K staff and 5K volunteers

• 3 Million Patients in 22+ counties across

100 California communities

Sutter Health – Sacramento, CA

• POLST introduced through

legislation in 2008

• Became effective January 1, 2009

– Widespread use of POLST

across the state

• At Sutter year-end 2017 (just prior

to go-live):

– 150,000+ POSLT forms on file

– 2,700 new forms each month

– 40% of patients aged 65+ with a

POLST or advanced directive

California Story

• Key Challenges – Inappropriate care due to:

– Paper form and reliance on human processing

• Scan to wrong document type – POLST lost in record

• Scan to wrong chart – POLST lost in another record

• Delay in scanning of form in record – POLST not available

• Form does not contain all elements to be legally valid – POLST not legal

• Form contains conflicting wishes – Cannot interpret POLST

• Form legibility and/or scan quality poor – Cannot read POLST

• Multiple forms with no known signature date – Most current POLST unclear

– 87% paper forms not available in an emergency

[1]

Not viewable by clinicians outside the Sutter network, and in

some cases inside our network

At Sutter, We Could Do Better…

[1] The Journal of Emergency Medicine, Vol. 44, No. 4, pp. 796–805, 2013

• Clinical Care:

– Concordance of Care: wherever the patient receives care

– Improved timely access to POLST forms in an emergency

– Enable just-in-time quality assurance for patients admitted to ICU

with a POLST that states comfort care only

• Business Acumen:

– Reduce healthcare legal risks

• Non-concordant care or following orders on a non-legal form

– Improve organizational reputation

• Delivery of care concordant with patient wishes even when patient is

outside the organization network

– Align with patient/population health strategy

Organizational Readiness

Participation in an eRegistry

• Engagement:

– Increase patient and provider satisfaction

– Increase community collaboration

• Quality Data:

– Ability to cull detailed data related to POLST use, choices made and

impact on care

– Allow transparency of how often a POLST form is viewed

appropriately for targeted educational purposes

– Mitigation or elimination of inherent issues with paper forms

– Quality metrics

• Education:

– Improve organizational culture associated with quality end-of-life

conversations

Organizational Readiness

Participation in an eRegistry

• In 2014, determined we needed to use an external vendor (build vs. buy)

– Internal requirement was to allow for concordance of care outside our

network

– Committed to solving with an EMR integrated solution

– Leverage technology to improve:

• Advanced Illness Management (AIM) and palliative care programs

• Integration with the state registry pilot

• Outcomes:

– ACP conversation/informed decision making

– ACP document preparation and storage rates

– Readmission rates ICU utilization

– Concordance of care

Solution Focused Goal

Securely house uploaded POLST forms on a cloud platform accessible

by providers across the state

The EMR

could not

accomplish

this goal

The EMR

could not

accomplish

this goal

• Began work to procure funding for project and seek a vendor

– All knew this was ‘the right thing to do’ but not sure a priority of senior leaders

– Defined correlation to strategic goals and key change management strategies

– Selected Vynca

• Patient matching

• eSignature

• Quality checks

• EMR flexibility

• California SB 19 (2015) requires POLST eRegistry Pilot in two counties

– Allowed us to finalize funding and gain approval to move forward with pilot

– California also selected Vynca as their “vendor of choice” for state registry

pilot

We now know what to do….

but how to do it?

Change Management

Six Strategies for Success

1. Correlation to strategic goals

2013 Strategic Level 1 A3: Coordinate Care Across the Continuum

• Level 2 A3: Integrated Palliative Care

– Design and pilot scalable patient-centered Integrated

Palliative Care Model – Experiment #1:

– Model requirement impact:

• Address clinical, operational and infrastructure gaps to

deliver enterprise wide PC

 ACP strategies

• Improve quality of care for patients/families

 Driving to full concordance of care

Key Change Management Strategies

2. Robust vendor choice requirements:

• PHI protection

• Safety

• Ease of use

• Adoption

• EMR integration

• Fit into clinical workflow

• Quality

• Cost

• Performance improvement

Key Change Management Strategies

3. Leverage state legislation SB 19 2015

• Stay ahead of the coming requirements

• Have a say in the rule making

• Lead the healthcare community in your state

4. Stakeholder involvement

• Blind spot identification and proactive solution generation

– Processes such as Release of Information

– Reporting methodology for ACP metrics

• EMR decisions – ensure future state matches current workflows

• Testing and feedback

• Training

Key Change Management Strategies

5. Human Error Proofing

• Decision to close the scan doc type POLST to all but HIM after a

period of both pathways being open

6. Robust training tools and communication planning

• Cannot rely on the cascade method of communication

Go live February 2018

Key Change Management Strategies

Training & Support Plans

• Special Challenges

– Big bang vs. pilot

– Affects POLST access workflows for clinicians

– Can potentially impact concordance of care for

one or more patients

• Getting the word out!

– Direct marketing to providers

– Cascade methodology

– Other tools for individual education

– IT support

Access: User Roles

Default Configuration

What we Learned

• Care risk as patient moves through

geographies

• Not technically possible with one

instance of Epic

Not

possible

to pilot in

small

scale

• Most ROI types include POLST form

and release is automated

• Pulls scanned doc type POLST

• Manual ROI not an option

Release of

Information

Process

(ROI)

interrupted

Enterprise

wide go-

live

Separate

interface

to allow

all

POLST

docs to

return

What we Learned

• POLST link found in patient level data;

some staff had encounter level access

only

Personnel

access

templates

to POLST

link

• Unaware Haiku photo forms stored on

separate BLOB server – not included

in upload of forms

Survey of

POLST

storage

locations

challenging

Developed

access

though

snapshot

Temporarily

re-opened

media tab

view to doc

type

POLST

What we Learned

• Entered signature dates when scanning form

would allow software to identify most current

valid form

• One Touch+ (inpatient) had this functionality;

only an issue in ambulatory setting.

Hyland

OnBase did

not allow for

signature

dates

• Still many paper forms used which cannot be

read for content

• Care at end-of-life requires manual chart review

which is not feasible

Elusive

concordance

of care rate

eTool use

is the

solution

Plan

development

in process

What we Learned

• Change in high-value

low occurrence

workflow requires deep

communication

penetration

• Risk: providers use old

POLST viewing method,

do not see a POLST,

assume patient does

not have a POLST:

Potentially results in

care not concordant

with wishes

Messaging

providers

at this

scale

Short messaging

Prioritize messages

Many platforms/venues

Champions

Tool kits

Utilize vendor expertise

Face-to-Face, simple fun

posters, fliers, and

“2clicks” sheets best

methodology

• 2017: Before Go Live:

• 150,000+ POSLT forms on file

• 2,700 new forms each month

• 40% patients 65 years and over with an ACP document

• Post Go Live February 2018:

– More than 180,000 existing POLST were located and back-loaded

– Electronic access to all of these forms within the EMR

– In first 14 weeks, 764 ePOLST documents were completed

– Now track who is engaging with POLST forms

• Majority of forms were completed by providers who are able to

legally sign the forms

• Initial results – 3% of forms having nurses/social work involvement

in preparation

Metrics for Success – Sutter

Metrics for Success – Sutter November ‘18

Metrics for Success – Sutter December ‘18

Next Steps for Sutter

• Final closure of historical workflow in EMR

• Awareness and Utilization Campaign to drive eForm use

– Benefit awareness

– Data use (form access count by provider type, medical group, clinic)

• Optimization

– Associated EMR functionality

• Yes/No form presence flag

• Auto complete of MD/NP credentials

– Metrics

– Just-in-time patient intervention review

• Continue sharing Sutter experience

– Community

– State

– National

• Critical in building a sustainable and comprehensive approach:

1. Widespread confidence in concordance of care

2. eRegistry well integrated throughout the medical community

3. POLST data collection

• Key Stakeholders:

– Strong network of engaged stakeholders who support the POLST eRegistry

initiative

– Address privacy and security in process of data sharing forms

– Lead organization communicates clearly and frequently with community

entities

– Understanding of how to participate, value, timing, and resource requirements.

Community Considerations

Organizational readiness

Participation in an eRegistry

Self-assessment Tool

• Purpose:

– Explore topics which influence successful approach to an eRegistry

– Explore the value prop

– Identify areas which need special attention/change to be ready

– Provide supportive evidence of organizational readiness to leaders

• Self-assessment questions to address:

– Technical, policy and operational elements

– Where opportunities are identified, an internal POLST project team should convene to

discuss possible approaches

• Community involvement key:

– Tool should be distributed for use by other members of the healthcare community

– Community members may then use the completed assessments to identify and review

areas of organization and community-wide need that may require collaborative effort

• Health Information

Technology & Data

Exchange Capacity

• POLST Input

Readiness

• POLST Retrieval

Readiness

• POLST Project Staffing

and Administrative

Capacity

• Community

Considerations

Assessment Tool

Sample of Tool

Please take

a picture of

the sample

tool at your

table

Please take

a picture of

the sample

tool at your

table

Needs to be tied to a local group or coalition

Integration into clinical workflow

Mandatory submission of documents

Easy access to data in emergency settings

Electronic documentation

Marketing and awareness

Sustainable funding

Participation and adoption by health care organizations

What Ensures Long-term Success of a

State Registry?

• A look at the pilot in Contra Costa county

– 218,000+ POLST forms

– Submissions portal

• Available to all providers with NPI number

• 1,122 forms uploaded

– PointClickCare integration with five SNFs

– American Medical Response MEDs ePCR

• 43 active EMS users

California eRegistry Pilot

Oregon POLST Registry (OPR) live since 2009

• Oregonians who died that had a completed POLST form

– 45% 2015-2016

– 31% 2010-2011

• When POLST forms had been completed

– 21 weeks from death 2015-2016

– 5 weeks from death 2010-2011

– Alzheimer’s and Parkinson patients completed forms earlier

• Opted for more aggressive treatment

– 13% requested CPR

– 11% requested full medical treatment

A Look at Oregon

https://www.liebertpub.com/doi/10.1089/jpm.2018.0446

Impact Across the State

IMPACT (April 2015 – July 2017)

5,711

reduction in ICU

admissions when

POLST was

accessed

37%

reduction in

hospital

admissions when

POLST was

accessed

ED visits in patients who

had POLST forms

59%

• Kathy Blanton

BlantK2@sutterhealth.org

• Ryan Van Wert, MD

ryan@vyncahealth.com

Questions

Appendix

Standard User Workflow

Signer

Standard User Workflow

Preparer

Standard User Workflow

Uploader

Standard User Workflow

View Only